PONE-D-21-12775

Knowledge, attitude, and practice of seasonal influenza and influenza vaccine immunization among people visiting primary healthcare centers in Riyadh, Saudi Arabia

PLOS ONE

Dear Dr. Alqudah,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Aug 08 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Livia Melo Villar

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

Additional Editor Comments (if provided):

Dear Author,

This manuscript intends to assess the knowledge, attitudes, and practices of seasonal influenza and influenza vaccine immunization among clients visiting healthcare centers in Riyadh, Saudi Arabia.

This information is very useful to recognize gaps to increase vaccine coverage in this population. I suggest the revision of the paper as reviewers comments to increase the relevance and quality of the paper,

sincerely,

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Main questions/comments:

- Is there a program also for the elderly and healthcare workers? Could you explain more about the Influenza vaccination program in Saudi Arabia, the target groups, numbers of individuals and access to vaccine (public or private?)

- Data on literature presented from lines 112 to 221 could be transferred to the discussion section, comparing to the data you generated in the article, or make it shorter.

- Were the answers to the questions about Knowledge and Practices with multiple choices or short answers? Please explain that.

- On table 3 it is reported that 356 individuals answered yes to the question “Does the vaccine have side effects?” However, on the lines below, 414 and 398 participants stated that vaccine causes Soreness and Fever, respectively. Please, check these numbers.

- Please make it clearer what was the knowledge added to the field of your study compared to Sagor and AlAteeq’s (2018) Alqahtani et al.’s (2017) and study.

English review:

Page 1 line 11: “The study investigated the relationship…” instead of “will investigate”

Line 21 “43.7% of participants had ever received” instead of “were ever received”

Page 2, line 49: the correct is “flu epidemics” not endemics

Line 55: “influenza infections across the world affects an average of five million people” sounds better than the original sentence

Line 64: find a better reference for this sentence, a scientific paper instead of Medscape

Line 70: use “its development” instead of “their development”

Page 3 line 71-72: please reformulate the sentence “The goal of the influenza vaccine is to protect against disease and achieve high vaccination rates” The vaccine itself doesn’t have the goal of achieving high vaccination rates.

Line 77: remove the word “scare”

Page 12 line 257: change “the questionnaire was clear and shows an acceptable level of internal reliability” to “the questionnaire was clear and showed an acceptable level of internal reliability”

Line 272 Please change “3. Have you ever heard of a vaccine prevent flu?” to “3. Have you ever heard that a vaccine could prevent flu?”

Line 388: change “There were 43.7% of participants (267 out of 611) were ever received flu vaccine ” to “There were 43.7% of participants (267 out of 611) that ever received flu vaccine”

Reviewer #2: The manuscript titled "Knowledge, attitude, and practice of seasonal influenza and influenza vaccine immunization among people visiting primary healthcare centers in Riyadh, Saudi Arabia" by Norah Alhatim, Ahmad M. Al-Bashaireh and Ola M. Alqudah presents a cross-sectional, descriptive and correlational study to assess the knowledge, attitudes, and practices (KAP) of seasonal influenza and influenza vaccine immunization among four Riyadh’s primary healthcare centers.

Through the data found, it is clear the need to invest in public awareness policies to increase population adherence in vaccination campaigns in order to mitigate potential new epidemics.

The lack of basic and scientific knowledge, combined with religious factors, can contribute to vaccine-refractory attitudes. This theme, when extrapolated to the Covid pandemic, shows the importance of investing in vaccine adherence campaigns with the support of local competent authorities.

Reviewer #3: The work presented here by Alhatim et al. brings a very interesting data concerning knowledge, attitude, and practice of seasonal influenza and influenza vaccine immunization, in Saudi Arabia. Although, this study showed concise results I feel that the manuscript needs to be improved and a wider revision on the theme need to be done, so the article can benefit greatly from a deeper immersion on currently published works. In this sense, some of my suggestions are listed below.

Major points:

In my opinion the manuscript needs to be actualized, benefiting greatly with the inclusion of several studies listed in this revision (discussion section below).

- Introduction

In my opinion some paragraphs can be removed and other can be presented in a simple and lean way. Paragraphs from line 141 to 183 should be removed and the ones from lines 184 to 228 can be moved to the discussion section in a more concise form.

- Discussion

As mentioned before it needs to incorporate related studies that will give the reader a better understand of your results and the published literature in similar subjects.

Discussion and introduction sections will benefit greatly from the following articles:

Aljamili AA. Knowledge and practice toward seasonal influenza vaccine and its barriers at the community level in Riyadh, Saudi Arabia. J Family Med Prim Care. 2020 Mar 26;9(3):1331-1339. doi: 10.4103/jfmpc.jfmpc_1011_19.

Alabbad AA, Alsaad AK, Al Shaalan MA, Alola S, Albanyan EA. Prevalence of influenza vaccine hesitancy at a tertiary care hospital in Riyadh, Saudi Arabia. J Infect Public Health. 2018 Jul-Aug;11(4):491-499. doi: 10.1016/j.jiph.2017.09.002.

Alotaibi FY, Alhetheel AF, Alluhaymid YM, Alshibani MG, Almuhaydili AO, Alhuqayl TA, Alfayez FM, Almasabi AA. Influenza vaccine coverage, awareness, and beliefs regarding seasonal influenza vaccination among people aged 65 years and older in Central Saudi Arabia. Saudi Med J. 2019 Oct;40(10):1013-1018. doi: 10.15537/smj.2019.11.24587.

Sales IA, Syed W, Almutairi MF, Al Ruthia Y. Public Knowledge, Attitudes, and Practices toward Seasonal Influenza Vaccine in Saudi Arabia: A Cross-Sectional Study. Int J Environ Res Public Health. 2021 Jan 8;18(2):479. doi: 10.3390/ijerph18020479.

Zaraket H, Melhem N, Malik M, Khan WM, Dbaibo G, Abubakar A. Review of seasonal influenza vaccination in the Eastern Mediterranean Region: Policies, use and barriers. J Infect Public Health. 2020 Mar;13(3):377-384. doi: 10.1016/j.jiph.2020.02.029.

Balkhy HH, Abolfotouh MA, Al-Hathlool RH, Al-Jumah MA. Awareness, attitudes, and practices related to the swine influenza pandemic among the Saudi public. BMC Infect Dis. 2010 Feb 28;10:42. doi: 10.1186/1471-2334-10-42.

Alshammari TM, Yusuff KB, Aziz MM, Subaie GM. Healthcare professionals' knowledge, attitude and acceptance of influenza vaccination in Saudi Arabia: a multicenter cross-sectional study. BMC Health Serv Res. 2019 Apr 15;19(1):229. doi: 10.1186/s12913-019-4054-9.

Awadalla NJ, Al-Musa HM, Al-Musa KM, Asiri AM, Albariqi AA, Majrashi HM, Alasim AA, Almuslah AS, Alshehri TK, AlFlan MA, Mahfouz AA. Seasonal influenza vaccination among primary health care workers in Southwestern Saudi Arabia. Hum Vaccin Immunother. 2020;16(2):321-326. doi: 10.1080/21645515.2019.1666500.

Alolayan A, Almotairi B, Alshammari S, Alhearri M, Alsuhaibani M. Seasonal Influenza Vaccination among Saudi Children: Parental Barriers and Willingness to Vaccinate Their Children. Int J Environ Res Public Health. 2019 Oct 31;16(21):4226. doi: 10.3390/ijerph16214226.

Balaban V, Stauffer WM, Hammad A, Afgarshe M, Abd-Alla M, Ahmed Q, Memish ZA, Saba J, Harton E, Palumbo G, Marano N. Protective practices and respiratory illness among US travelers to the 2009 Hajj. J Travel Med. 2012 May-Jun;19(3):163-8. doi: 10.1111/j.1708-8305.2012.00602.x.

Alqahtani AS, Rashid H, Heywood AE. Vaccinations against respiratory tract infections at Hajj. Clin Microbiol Infect. 2015 Feb;21(2):115-27. doi: 10.1016/j.cmi.2014.11.026.

Minor points:

Abstract

Page 1 line 2 and 3: rephrase the following sentence: “Influenza infection is a continuing threat to the Saudi population, resulting in high mortality rates and disease prevalence; it also puts significant financial strain on the country.”

Introduction

This section needs to be shortened and actualized (please see articles suggested at the discussion section).

Page 3 line 57: remove: “However, it affects all age groups and is usually self-limited [4]”

Materials and Methods

Page 11 - Line 236-239: Informe the period (years) of data collection.

Page 12/13 - Line 262 -293: Variables and Domains should be presented in a box instead of being listed in the text. This way will be easier for the reader to have access to the information.

Results

Page 15 line 331: “When asked about the flu”

Page 15 line 337: Table 1. Socio-demographic characteristics (N = 611).

Page 18 line 362-370: Tables 4 to 7 should be merged in a unique table with all information.

Page 19: Table 9 should be excluded the information is already on the text. This Table brings no additional information to the reader, this suggestion is also applicable for Tables 11, 12 and 14 on page 20, 21 and 22, respectively.

Discussion

See Major points above.

Recommendations

It’s very important to include here proposals of how increased education regarding influenza and vaccinations can be achieved, which activities need to be better addressed and which should be strengthen.

Conclusion

Page 26 - Lines 520 to 523: remove

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Yasmine Rangel Vieira

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PONE-D-21-12775R1Knowledge, attitude, and practice of seasonal influenza and influenza vaccine immunization among people visiting primary healthcare centers in Riyadh, Saudi ArabiaPLOS ONE

Dear Dr. Alqudah,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please address reviewer 1's comments. Please also address the following requests:

• In your methods section, please provide additional information about the participant recruitment method and the demographic details of your participants. In particular, please include a statement as to whether your sample can be considered representative of a larger population. In addition, please further discuss as a limitation in the Results or Conclusion section the non-representativeness of your sample (in particular the relatively high rate of respondents who attended college).
• PLOS ONE does not copy edit accepted manuscripts. Please proofread for typos and grammar, including in the abstract.

Please submit your revised manuscript by Jan 08 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Yann Benetreau, PhD

Senior Editor (Staff editor), PLOS ONE

 

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

********** 

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

********** 

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

********** 

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

********** 

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

********** 

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I think the review answered all the questions and points I had raised and the new version has been improved substantially. Just another question that arose when I read the reviewed manuscript. The data collection for this study was from January to July 2020. It would be important to include one or two sentences discussing the impact of Covid-19 pandemics on the results obtained in this study, compared to previous years, without the threat of a respiratory pandemic.

Reviewer #2: (No Response)

********** 

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Knowledge, attitude, and practice of seasonal influenza and influenza vaccine immunization among people visiting primary healthcare centers in Riyadh, Saudi Arabia

PONE-D-21-12775R2

Dear Dr. Alqudah,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Sincerely yours,

Yann Benetreau, PhD

Division Editor, PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: